2013: Year in Review

Physician Pipeline, Workforce Issues Dominate Medical Education Scene

Growing the nation's workforce of family physicians commanded a good deal of the AAFP's attention in 2013. Throughout the year, Academy leaders, primary care advocates and others strived, in particular, to hammer home the need for graduate medical education (GME) and other reforms designed to produce a physician workforce that aligns with the nation's evolving health care needs.

Neil Kalsi and Charity Kaiser of St. Louis University School of Medicine are two of the nearly 3,000 medical students who matched into family medicine residency programs on March 15. Both are headed to the Northwestern McGaw Family Medicine Residency Program in Chicago.

March saw yet another uptick in the number of medical school graduates choosing careers in family medicine, according to results of the National Resident Matching Program, commonly known as the Match. Out of 3,062 residency positions offered -- the most since the 2001 Match -- 2,938 positions were filled, for a fill rate of 96 percent.

In August, the AAFP's yearly national survey of family medicine residencies reinforced the positive news, showing that 67.4 percent of first-year family medicine residents graduated from U.S. allopathic or osteopathic medical schools in 2013, compared with 58 percent in 2009.

Even so, according to AAFP medical education experts in an October analysis of Match data, neither an increase in the number of family medicine residency programs available nor the boost in numbers of U.S. medical students entering family medicine will be enough to increase the nation's primary care workforce to the overall 40 percent level recommended by GME policy experts.

An accompanying article that examined factors guiding students' specialty choices found that where medical students attend school, as well as their experiences while in school, play key roles in shaping their career choices. According to corresponding author Wendy Biggs, M.D., it's important that students have a chance to observe family physicians providing "full-scope health care out in the community," which is less likely to happen in academic tertiary medical center settings in large, urban areas. To address this issue going forward, Biggs said the AAFP could continue to encourage "community-based education," something that already is happening in medical schools that have branch campuses located away from their urban-based teaching hospitals.

Meanwhile, the Association of American Medical Colleges said in a report published in May that even as enrollment at U.S. allopathic and osteopathic medical schools continues to rise at a steady pace, academicians and policy experts are increasingly concerned that insufficient numbers of residency training positions -- especially those in primary care -- will be available to meet matriculating students' GME needs.

That's despite well-intended attempts to address the problem, such as that demonstrated in the Medicare Modernization Act of 2003, which sought to address the ongoing shortage of primary care physicians by training more residents in primary care and in rural areas largely through the redistribution of unused GME slots. The legislation failed to accomplish its goal, according to researchers with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, because monitoring systems were not in place and medical schools had a strong financial incentive to train more subspecialists.

More recently, Graham Center researchers found that despite a 22.9 percent increase in total U.S. medical school enrollment between 2000 and 2010, many states still face primary care shortages. The researchers' conclusion: Uncoordinated expansion of medical schools is not likely to solve health care access challenges.

Social Accountability in Medical Education Needed

A study published in June by researchers from George Washington University, the Graham Center, and the American Board of Family Medicine (ABFM) confirmed that America's medical education system is not producing enough primary care physicians to meet the country's needs and pointed to flaws in the GME funding mechanism that supports physician training.

"Primary care physician production of 25.2 percent and rural physician production of 4.8 percent will not sustain the current workforce, solve problems of maldistribution or address acknowledged shortages," said lead study author Candice Chen, M.D., M.P.H., in an accompanying news release(www.graham-center.org).

Given that America's physician workforce is funded, in large part, by taxpayers' investment in GME funding provided through Medicare ($10 billion) and Medicaid ($3 billion), it's only fair that Americans hold the U.S. medical education system accountable for the types of physicians it produces.

"National calls for more primary care physicians, general surgeons, psychiatrists and providers in rural and urban underserved areas are thwarted by federal funding that continues to support training programs without requiring measurement of, much less accountability for, what they produce," study co-author and Graham Center Director Andrew Bazemore, M.D., M.P.H., observed.

Some experts -- Chen among them -- think that the five-year, $230 million Teaching Health Center Graduate Medical Education program established by the Patient Protection and Affordable Care Act could play an important role in remedying the shortfall in primary care residency positions and hiking the number of residency graduates who care for vulnerable populations in underserved areas.

Although the program, which provides funding directly to community-based training sites, may be small, "its inclusion in the Affordable Care Act sends a message to the medical community," said Chen. "It shows that there's national interest in primary care and community-based training."

That direct funding is essential, she added, "because those are the people who should drive the focus and mission of primary care residency programs, and the funding gives those sites more leverage in partnering with hospitals."

Residency program directors at these community-based sites lauded the program, saying it is particularly well-suited to providing trainees with an immersion experience that encompasses the full scope of family medicine, nurtures cultural proficiency and promotes an integrated, team-based approach to care.

Notably, one of those grants went to fund a new GME model that aims to help address America's shortage of primary care physicians by creating a multistate, centrally run medical residency program that would offer osteopathic residents modern ambulatory training "coupled with carefully selected hospital training experiences using an innovative, nationally accredited residency curriculum." The program would place as many as 29 osteopathic medical school graduates each year for three years in community health centers located in medically underserved areas across the country.

"It is our hope to provide a continuum of education so that the medical students we're training can go into practice where they are needed," said Thomas McWilliams, D.O., associate dean of GME at the A.T. Still University of Health Sciences School of Osteopathic Medicine in Mesa, Ariz.

Ted Epperly, M.D., speaks to a resident at the Family Medicine Residency of Idaho, Boise. Epperly was one of five residency directors who recently talked to AAFP News Now about teaching health centers and the future of family medicine training.

If a recently published study by Graham Center researchers is any indication, similar results could be seen among residents who train in safety-net settings, such as federally qualified health centers, rural health clinics and critical-access hospital. Residents trained in such settings, researchers found, are more likely to return to practice in a similar setting.

But the fact remains that the GME funding system is beset by even more basic issues of inequity based on geographic factors, according to a report in the November issue of Health Affairs. In a state-by-state analysis of Medicare cost reports from teaching hospitals, researchers found significant differences in overall Medicare GME payments, as well as in the average payments per person and payments per medical resident, with the imbalance tilting in favor of programs in the Northeastern states.

Not Just by the Numbers

Boosting the numbers of family and primary care physicians, however, even coupled with efforts to ensure those physicians practice in the areas in which they are most needed, isn't enough to ensure a workforce that is adequately equipped to deal with existing and nascent challenges posed by a rapidly evolving U.S. health care system.

At a primary care forum the ABFM hosted in March, speakers addressed the need for a primary care workforce that is trained in team-based and collaborative care. "If we are going to talk about innovation and change, we often have to change the faculty, because their natural inclination is to teach what they have been doing their whole careers and what they were taught," said George Thibault, M.D., president of the Josiah Macy Jr. Foundation, during the event.

Fortunately, said the speakers, medical education is undergoing fundamental changes in some parts of the country to better align with changes taking place in the health care system as a whole. One initiative, in particular, has identified the following skills and competencies needed for the primary care workforce of the future:

teamwork,

change management,

leadership,

population management and

clinical microsystem skills.

The ABFM, American Board of Internal Medicine and American Board of Pediatrics now are engaged in developing common goals and competencies for curriculum development to support integration of these elements into medical education.

Another innovative effort aims to create and test new health care organizations and structures while training a workforce that operates in team-based delivery systems to improve health care quality, safety and access.

All in all, policymakers would do well to heed recommendations contained in the 21st report from the Council on Graduate Medical Education (COGME) published in August, say AAFP medical education experts. According to COGME, past unsolved problems, including poor geographic distribution of the physician workforce and accelerating subspecialization at the expense of primary care, have collided with new challenges to create a crisis in medical education.

In response, the report offers six principal recommendations:

increase and broaden GME funding;

prioritize funding to quickly align the physician workforce with population and health delivery needs;

realign clinical learning and curricula to reflect patient-centered, safe and effective care; and

invest in medical education research to improve GME quality and physician competencies.

Regarding the quality of GME, the AAFP and other family medicine organizations lost no time responding last spring to a proposal from the Accreditation Council for Graduate Medical Education (ACGME) that would impose unwelcome women's reproductive health curriculum changes on family medicine residencies. (Then) AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., commented on the proposed changes, which were made as part of the ACGME's so-called Next Accreditation System, in an April 22 letter.

"We would like to communicate directly to the Review Committee for Family Medicine (the) concerns expressed by our membership regarding the removal -- from the draft Program Requirements for Residency Education in Family Medicine (RD-FM) -- (of) the specific references to curriculum in family planning and reproductive decision-making," said Stream.

"The AAFP wants the RC-FM to understand clearly that we remain firm in our policy commitment to women's health and contraception as essential components for the family physician's scope of practice," said Stream.

New CME Opportunities

Ensuring family physicians remain up-to-date in one particular area of practice was a key component of the risk evaluation and mitigation strategy (REMS) for extended-release/long-acting (ER/LA) opioids the FDA instituted in 2012; and 2013 brought the rollout of the first REMS-compliant CME funded by manufacturers of these drugs.

The agency issued an open letter to prescribers of ER/LA opioids to mark the March 1 deadline for the release of the first CME activities focusing on these drugs, inviting them to seek out and take advantage of the available training options.

"FDA remains committed to making sure that patients in need have continued access to appropriate pain medications, while also ensuring that all opioid products are used as safely and effectively as possible under the supervision of prescribers armed with sound information and training," said the letter.

As both a national CME accreditor and an accredited CME provider, the AAFP has been engaged in conversations with multiple stakeholders regarding the development and design of certification standards for REMS-compliant CME for ER/LA opioids, as well as the core messages to be covered in educational offerings for prescribers of ER/LA opioids.

2013 also brought family physicians and other health care professionals a rather unusual CME opportunity -- straight from a screening at the Sundance Film Festival.

The documentary film "Escape Fire: The Fight to Rescue American Healthcare"(www.escapefiremovie.com) focuses on the problems facing America's broken health care system and attempts to define solutions. The film and an accompanying round-table discussion featuring (then) AAFP President Jeff Cain, M.D., of Denver, initially aired March 10 and were rebroadcast March 16. Archived versions of the film and the round-table discussion remain available online.